This article was sent out to all Rex nursery employees by their new manager, Michele Clement. It is comprehensive, yet short enough to get to the point.
Authors and Disclosures
Karen Cleaveland, MSN, APRN, NNP-BC
Karen Cleaveland is a family nurse practitioner at Middlesex Hospital in Middletown, Connecticut, Connecticut’s fi rst Baby Friendly designated hospital. She holds dual certifi cation as a neonatal nurse practitioner from the University of Connecticut. She received her master’s in nursing from St. Joseph College in West Hartford, Connecticut. She is also employed at the University of Connecticut Health Center in Farmington in the Level III NICU.
For further information, please contact: Karen Cleaveland, MSN, APRN, Middlesex Hospital, 28 Crescent Street, Middletown, CT 06457, E-mail: firstname.lastname@example.org
From Neonatal Network
Feeding Challenges in the Late Preterm Infant
Karen Cleaveland, MSN, APRN, NNP-BC
Posted: 03/04/2010; Neonatal Network. 2010;29(1):37-41. © 2010 Neonatal Network
Abstract and Introduction
A late preterm infant is defined as one born between 34 and 36 6/7 weeks of completed gestation. The rate of late preterm births has risen 18 percent since the late 1990s. Data are beginning to emerge concerning morbidity rates and the risks these newborns face with regard to feeding difficulties, temperature instability, hypoglycemia, and hyperbilirubinemia. Feeding challenges place these vulnerable infants at risk for prolonged hospital stays and readmission after discharge. To better address the unique needs of late preterm infants, providers should establish individual feeding orders. This article offers research-based suggestions for caring for these infants in the newborn nursery and the postpartum unit as well as parent teaching guidelines.
Late preterm infants represent the most rapidly growing segment of preterm births in the U.S., accounting for 72 percent of the 12.7 percent preterm birth rate in 2005. This population of preterm infants is often cared for within the general newborn setting using the feeding guidelines for healthy term infants. The staff of the newborn nursery often regards these infants as being term because they are usually of normal size and have a more mature appearance than preterm infants born after shorter gestations. Compared with term infants, however, late preterm infants are at higher risk for excessive weight loss, feeding intolerance, hyperbilirubinemia, hypoglycemia, hypothermia, respiratory distress, apnea of prematurity, and a weak suck. And, because of the increased risks these infants face, they also have higher morbidity and mortality than term infants. It is therefore necessary to recognize and treat this late preterm infant population with its own feeding and care guidelines instead of using guidelines for term infants. It is also vital to formulate a specific set of discharge planning teaching guidelines for them.
In 2005, a National Institute of Child Health and Human Development (NICHD) consensus panel recommended the use of the phrase late preterm to describe infants born at 34 0/7 to 36 6/7 completed weeks of gestation. Before the panel’s recommendation, there was no uniform designator for this population, although the descriptors near-term and preterm were among those used. The NICHD panel members agreed that there was a need for uniformity and specificity in designating infants of this gestational period. They believed that adoption of the descriptor late preterm infant would provide the impetus for treating these infants based on their own needs and risks.
Risk Factors Affecting Feeding
According to Wang and colleagues’ comparison of 125 neonates born between 35 and 36 6/7 weeks with 120 neonates born at term (37–41 weeks), the rate of respiratory distress was 28.9 percent in the late preterm group, but only 4.2 percent in the term group. The presence of respiratory distress in the late preterm infant has a significant impact on feeding, often delaying the initiation of oral intake until the infant’s respiratory status has stabilized. For safe and efficient oral feeding, infants must be able to smoothly and effectively synchronize sucking, swallowing, and breathing, with highly accurate timing and coordination. Coordination of these activities is essential to avoiding aspiration and swallowing of air and to the efficient intake of nutrients.
Thermal instability is common in the late preterm infant, with approximately 10 percent requiring active intervention to relieve the hypothermia. The presence of hypothermia increases the infant’s oxygen consumption and work of breathing and can exacerbate signs of respiratory distress. Hypothermia also places the infant at risk for developing hypoglycemia. Late preterm infants’ temperatures should be closely monitored to prevent hypothermia because cold stress can lead to worsened hypoglycemia among these infants. Use of calories to generate heat may result in the infant’s having less energy for feeding.
Another common problem in the newborn population is hyperbilirubinemia. Late preterm infants are 2.4 times more likely than term infants to develop significant hyperbilirubinemia, and one in every four late preterm infants requires phototherapy. Watchko also stresses that the documented higher risk of hyperbilirubinemia and kernicterus among late preterm infants reinforces the importance of not treating the late preterm infant as a term infant. Late preterm infants need proper follow-up care within a few days of birth to ensure that adequate feedings have been established, especially with those who are being exclusively breastfed. Although there is a correlation between exclusive breastfeeding and risk for hyperbilirubinemia, it is likely that suboptimal (rather than exclusive) breastfeeding, resulting in dehydration and inadequate nutritional intake, causes the increased risk.[8,9]
Feeding challenges in the late preterm infant have been shown to be related to immature sucking and swallowing reflexes, which lead to improper latch-on for the breastfeeding infant as well as inadequate intake in the bottle-feeding infant. As noted earlier, sucking, swallowing, and breathing must synchronize smoothly and effectively, with highly accurate timing and coordination, for safe and efficient oral feeding. Late preterm infants often have fewer awake-alert periods and less postural stability than their full-term counterparts, which often results in inadequate caloric intake. Decreased feeding combined with low energy stores and high energy demands place these infants at risk for inadequate hydration. Health care providers and mothers may assume that the infant has ingested an adequate volume of milk when he falls asleep at the breast, when in reality the infant has exceeded his energy stores and has shut down without adequate caloric intake. Parents need to be educated regarding their infant’s feeding cues, sleep-wake cycles, and how to promote postural stability. Behaviors such as rooting, mouthing, and finger sucking indicate feeding readiness. Ensuring that the hips are flexed and the head and neck are aligned with the trunk provides appropriate postural stability, improving feeding success in the late preterm infant.
Immature brain development in late preterm infants is often overlooked because they are considered stable compared with extremely low birth weight premature infants. During the final few weeks of gestation, movements become smoother, oral motor skills more coordinated, and states of alertness more predictable. This relates directly to why late preterm infants fail at feeding when they are discharged without the proper instructions being given to their caregivers. It is necessary that the nursing staff and parents, as well as the pediatric providers, receive education in achieving safe and effective oral feedings in late preterm infants. The medical issues described earlier also make late preterm infants more susceptible to having a decreased state of arousal as well as poor endurance, resulting in early fatigue during feeding.
A newborn admitted to our special care nursery (SCN) after being born to teen parents at 36 weeks gestational age exemplifies the complexities of the late preterm infant. Baby C was born to an 18-year-old, gravida 1, para 0 mother, who presented with preterm labor, which progressed quickly to delivery. Maternal laboratory tests included: Blood type: A+, rubella: immune, Group B Streptococcus (GBS): negative, Human immunodeficiency virus (HIV): negative, hepatitis B surface antigen (HbSag): negative, rapid plasma reagin (RPR): nonreactive, gonococcus (GC)/Chlamydia: negative. The mother was given narcotic analgesia prior to delivery because of inadequate pain relief from her epidural anesthesia. Baby C was born with mild respiratory distress exhibited by grunting respirations and subcostal retractions. He was brought to the SCN for evaluation after receiving naloxone because of his weak respiratory effort. The mother began feeding the infant within four hours of delivery. Because she expressed a desire to breastfeed, she was given a breast pump to use every three to four hours to express milk that could be used to supplement Baby C’s direct breastfeeding. Because Baby C was a late preterm neonate, his suck was weak, he had fewer awake-alert states, and he did not exhibit the usual signs of feeding readiness such as rooting, lip smacking, and finger sucking. If he had been allowed to suck only from the breast, he likely would not have received all the breast milk he needed.
Expressed breast milk was fed to Baby C through a supplemental nursing system (SNS), which utilizes a small tube attached to the maternal nipple. The tube delivers a steady flow of milk to infants who have difficulty extracting milk directly from the breast. The use of the SNS with expressed breast milk allowed Baby C to ingest a measured amount of milk while also allowing him unrestricted access to the breast. After about 30 hours of this feeding cycle, a bilirubin level was obtained. Phototherapy was initiated with a total bilirubin level of 10.8 micromol/liter. As a result of Baby C’s ineffective sucking, sleepiness, and high bilirubin level, alternate feeding methods were implemented. These included finger feeding and the use of a Haberman feeder, a specialized feeding bottle with a valve and teat mechanism to adjust the milk flow to prevent overwhelming the baby with milk. Despite these measures, Baby C continued to lose weight because he was unable to take in the necessary measured feeding to ensure an adequate caloric and fluid intake. Ultimately, it became necessary to insert a nasogastric feeding tube (NGT) at 72 hours of age to meet his nutritional needs.
During the four days following insertion of the NGT, Baby C’s feeding plan was revised multiple times by different providers. If a formal feeding assessment by a certified lactation consultant had been initiated earlier, a feeding plan could have been established for this baby, alleviating confusion among team members. On day of life (DOL) 5, the health care team met to discuss Baby C’s situation. The team decided to give him a 48-hour period of exclusive feeding through the NGT to establish sufficient, sustained caloric intake and weight gain. Feeding by mouth (PO) was reintroduced on DOL 7, when Baby C exhibited positive feeding cues, such as sucking on his fingers and alertness. Baby C was then successfully transitioned exclusively to PO feedings over the course of the next few days and was discharged on DOL 12, after adequate weight gain. He was sent home with his parents with a feeding plan that called for the use of both expressed breast milk and formula.
Failure to immediately recognize the needs of this late preterm infant may have led to prolonged hospitalization and potential failure of breastfeeding. Baby C did not successfully transition to exclusive breastfeeding before his discharge, but with the assistance of the outpatient lactation consultant and the breastfeeding support group, he transitioned to breastfeeding almost exclusively at home.
Baby C is a good example of how evaluating newborns strictly on physical appearance and treating late preterm neonates as if they were term neonates can increase their susceptibity to complications such as hyperbilirubinemia and feeding difficulties. Wang and colleagues note that feeding problems are the dominant reason for discharge delays among late preterm infants, generating greater hospital costs. Late preterm infants, who exhibit feeding behaviors and skills more like those of premature than term infants, benefit when parents can discern their needs and respond supportively. Ludwig suggests teaching parents techniques such as pacing, appropriate postural support, feeding positions conducive to improved coordination, and reading cues of hunger and stress. It may be beneficial for these infants to utilize a cue-based feeding regimen. There are several lactation positions that are successful for the late preterm infant, including the dancer’s hand, which assists with stabilization of the infant’s jaw so he does not slip off the breast (Figure 1). The clutch or football and the cross-cradle positions allow a mother to support the infant’s trunk and control the flexion and extension of the infant’s head.
Figure 1. Dancers Hand.
If the infant is unable to successfully breastfeed within six hours after delivery, hand expression or pumping should be initiated. Mothers should utilize a hospital grade breast pump and be encouraged to pump eight to ten times in 24 hours.
It is clear from both research and practical application within a nursery that a protocol (Table 1) and a late preterm infant order set (Figure 2) designed specifically for these infants are called for to anticipate their unique needs. NICHD recognized the need for consistency in categorizing such infants because late preterm infants have specific needs and challenges. Grouping them with more premature infants could complicate their care. Placing them in the same category as term infants merely because they look physically developed and mature can cause caregivers to overlook their unique needs. Two prominent deficiencies in late preterm infants—feeding challenges and hyperbilirubinemia—can be dealt with much more efficiently if a distinct protocol is utilized. Overlooking such deficiencies initially can lead to prolonged hospitalization or readmission to the hospital and may deprive the infant of proper nutrition or the opportunity to breastfeed exclusively.
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Table 1. Late Preterm Infant Protocol
Assessment at Birth–24 Hours and Beyond
Parent Discharge Education
Review gestational age and hyperbilirubinemia risk factors.
Establish adequate feedings to reduce the incidence of hyperbilirubinemia.
Determine gestational age to assess risk for poor suck and swallow.
Signs of feeding readiness and infant cues include alertness and rooting.
Between 1996 and 2006, the rate of infants born late preterm in the U.S. increased more than 18 percent. It seems only prudent to develop a protocol to help decrease morbidity and mortality in these vulnerable infants.
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The author would like to extend a special thank-you to Susan Beebe, RN, IBCLC, for her support and knowledge in breastfeeding.
Neonatal Network. 2010;29(1):37-41. © 2010 Neonatal Network